First Name
*
Last Name
Email
*
Phone
*
Gender
*
Male
Female
Spouse FirstName
Relationship Status
*
Married
Separated
Divorced
Living Together
Dating
Do you or your spouse attend the Rock Church?
attend the rock
Yes
No
Not Sure
What's the condition of your relationship right now?
Current Status
*
GREAT - Keeps Getting Better
GOOD - Want To Improve Areas
STUCK - Limited by Bad Habits & Patterns
CONFLICT - Same Arguments Over and Over
CRISIS - Should I Go Or Should I Stay
SEPARATED - Looking for Healing
SINGLE - Seeking a Spouse
Which are the 3 Most essential qualities in your relationship?
Most Essential:
*
Trust
Imtimacy
Conflict Resolution
Communication
Love
Sex
Commitment
Other
What are 2-3 areas you would like breakthroughs in your relationship?
Areas for break-thru
*
Communication (heard, valued, understood)
Sex Life
Conflict Resolution
Freedom From the Past
Creating Trust Again
Intimacy (emotional & physical)
Commitment
Healing Past Wounds
Getting Your Needs Met
Possibilities For Our Future
My partner's got my back ...
1.1 Trust
*
Mostly
Frequently
50%
Sometimes
Rare
Agreements are kept ...
1.2 Trust
*
Mostly
Frequently
50%
Sometimes
Rarely
It feels safe to be vulnerable ...
1.3 Trust
*
Mostly
Frequently
50%
Sometimes
Rarely
We talk about our needs ...
2.1 Needs
*
Mostly
Frequently
50%
Sometimes
Rarely
My partner meets my needs ...
2.2 Needs
*
Mostly
Frequently
50%
Sometimes
Rarely
I understand and meet their needs ...
2.3 Needs
*
Mostly
Frequently
50%
Sometimes
Rarely
Our Communication feels Open, Honest & Safe
3.1 Communication
*
Mostly
Frequently
50%
Sometimes
Rarely
We feel heard, understood & valued ...
3.2 Communication
*
Mostly
Frequently
50%
Sometimes
Rarely
We avoid the blaming, and shame game ...
3.3 Communication
*
Mostly
Frequently
50%
Sometimes
Rarely
Conflict & Misunderstanding are met with compassion & curiosity ...
4.1 Conflicts
*
Mostly
Frequently
50%
Sometimes
Rarely
Conflict & Misunderstanding Bring us closer ...
4.2 Conflicts
*
Mostly
Frequently
50%
Sometimes
Rarely
Conflicts and Misunderstandings are Cleared up quickly ...
4.3 Conflicts
*
Mostly
Frequently
50%
Sometimes
Rarely
I feel I am emotionally met and safe ...
5.1 Intimacy
*
Mostly
Frequently
50%
Sometimes
Rarely
My needs for touch are met ...
5.2 Intimacy
*
Mostly
Frequently
50%
Sometimes
Rarely
Our Sex Life is Amazing ...
5.3 Intimacy
*
Mostly
Frequently
50%
Sometimes
Rarely
I healed my past wounds ...
6.1 Wounds
*
Mostly
Frequently
50%
Sometimes
Rarely
My Spouse healed their wounds ...
6.2 Wounds
*
Mostly
Frequently
50%
Sometimes
Rarely
We talk w/o triggers getting tripped ...
6.3 Wounds
*
Mostly
Frequently
50%
Sometimes
Rarely
Decisions are made together ...
7.1 Differences
*
Mostly
Frequently
50%
Sometimes
Rarely
Differences are embraced ...
7.2 Differences
*
Mostly
Frequently
50%
Sometimes
Rarely
Future Direction is discussed ...
7.3 Differences
*
Mostly
Frequently
50%
Sometimes
Rarely
Past ...
8.1 Our Past Relationship was ...
*
Full of Possibility
About Average
Full of Pain
Presently ...
8.2 Our Present Relationship is ...
*
Full of Possibility
About Average
Full of Pain
Future ...
8.3 Our Future Relationship Will be ...
*
Full of Possibility
About Average
Full of Pain
I See My Partner As ...
9.1 - I See My Partner As ...
*
Open - Available
About Average
Shutdown - Resistant
My Partner Sees Me As ...
9.2 - My Partner See Me as ...
*
Open - Available
About Average
Shutdown - Resistant
The best part of being in a relationship is ...
Best Part
*
The worst part of being in a relationship is ...
Worst Part
*
My Biggest Relationship Problem is ... (select from list)
biggest problem
*
Lack of emotional support
Issues around Sex
Dealing w/ Ex, Stepchildren, and In-Laws
Pain and Baggage From The Past
Jealousy
Lack of Commitment
Loss of Intimacy
Financial Issues
My Partner Doesn't Listen
The Romance is Gone
How Decisions are Made
We Can't Communicate Openly & Honestly
The Trust is Gone
Broken Agreements
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My Relationship With My Partner Would Be Great If Only ...
Great Relationship
*
I Have Tried
*
Reading Books
Podcasts
Workshops
Done Therapy
Got Coaching
Nothing Yet
How Pressing is Your Problem?
*
URGENT - destroying our relationship
PRESSING - could destroy our relaionship
IMPORTANT - we need to hand this issue
INTERESTED - don't have time or energy now
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Additional Survery Comments
*